Provider Demographics
NPI:1003261637
Name:LYNZE VICKERS, LMFT, LLC
Entity Type:Organization
Organization Name:LYNZE VICKERS, LMFT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYNZE
Authorized Official - Middle Name:
Authorized Official - Last Name:VICKERS
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:334-401-0595
Mailing Address - Street 1:3350 NOBLE WAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-7444
Mailing Address - Country:US
Mailing Address - Phone:229-333-0300
Mailing Address - Fax:
Practice Address - Street 1:3350 NOBLE WAY
Practice Address - Street 2:SUITE B
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-7444
Practice Address - Country:US
Practice Address - Phone:229-333-0300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-02
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT001430106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty